Alexander McMillan1, 2
(1)
Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk
(2)
University of Edinburgh, Edinburgh, Uk
Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer
Email: a.amcmm@btinternet.com
Abstract
Pierre, a 23-year-old student, attends a Sexual Health clinic with a 5-day history of urethral discharge and mild pain on micturition. There are no other urological symptoms. He had been treated 1 month previously for non-gonococcal urethritis (NGU) with a single oral dose of 1 g of azithromycin. Within several days of that treatment, he became symptom free. He tolerated the medication well without vomiting or diarrhea. He has been in a regular sexual relationship for 3 months with a 19-year-old woman who attended the same clinic and was screened for sexually transmissible infections. As is routine clinic practice she was treated with azithromycin at that time. NeitherChlamydia trachomatis nor Neisseria gonorrhoeae was detected in either partner, and Trichomonas vaginalis was not identified in a saline-mount preparation of vaginal material. They abstained from sex for 1 week after treatment, but since then they have had regular unprotected vaginal intercourse. Neither partner has had sexual contact with another person for at least 4 months.
Pierre, a 23-year-old student, attends a Sexual Health clinic with a 5-day history of urethral discharge and mild pain on micturition. There are no other urological symptoms. He had been treated 1 month previously for non-gonococcal urethritis (NGU) with a single oral dose of 1 g of azithromycin. Within several days of that treatment, he became symptom free. He tolerated the medication well without vomiting or diarrhea. He has been in a regular sexual relationship for 3 months with a 19-year-old woman who attended the same clinic and was screened for sexually transmissible infections. As is routine clinic practice she was treated with azithromycin at that time. NeitherChlamydia trachomatis nor Neisseria gonorrhoeae was detected in either partner, and Trichomonas vaginalis was not identified in a saline-mount preparation of vaginal material. They abstained from sex for 1 week after treatment, but since then they have had regular unprotected vaginal intercourse. Neither partner has had sexual contact with another person for at least 4 months.
22.1 How Would You Account for the Recurrence of His Presumed Urethritis?
Recurrent or persistent urethritis, occurring within 30–90 days of treatment of NGU occurs in up to 20% of cases. The etiology of recurrent urethritis is often uncertain, but unprotected intercourse with an untreated partner is a possible cause. If the history is accurate, this is unlikely in this case. Mycoplasma genitalium has been implicated as a cause in up to 20% of cases of NGU. Significant failure rates have been reported after treatment of M. genitaliumNGU with a 1 g single oral dose of azithromycin. The absence of T. vaginalis on direct microscopy vaginal material from his partner does not exclude this organism as the cause of recurrent NGU (see Case 10).
A mucoid urethral discharge is noted, and a Gram-stained smear shows >30 polymorphonuclear leucocytes per ×1,000 microscopical field but Gram-negative diplococci are not identified. Trichomonas vaginalis is not detected in a saline-mount preparation of urethral discharge. Urinalysis does not detect blood, protein, or nitrites. A first-voided specimen of urine is obtained for the detection of C.trachomatis, and a mid-stream specimen is sent to the laboratory for culture for urinary tract pathogens. Nucleic acid amplification methods for the detection of M. genitalium and T. vaginalis are unavailable.
The findings confirm a diagnosis of non-gonococcal urethritis. In the absence of additional clinical features such as frequency, nocturia, and urgency, a urinary tract infection is an unlikely cause of his urethritis.
22.2 How Would You Manage This Case?
Table 22.1 shows recommended treatment regimens for recurrent of persistent urethritis.
Table 22.1.
Recommended treatment regimens for recurrent or persistent non-gonococcal urethritis.
|
Azithromycin 500 mg as a single oral dose followed by 250 mg once daily for 4 days |
|
OR |
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Erythromycin 500 mg four times per day for 21 days |
|
PLUS |
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Metronidazole 400 mg twice daily for 5–7 days |
Metronidazole should be included in the regimen because T. vaginalis has not been excluded as a cause of his urethritis.
As mentioned above, single-dose treatment with azithromycin often fails to eradicate M. genitalium. Good results, however, have been obtained with azithromycin given as a single oral dose of 500 mg followed by 250 mg once daily for 4 days. Some physicians are concerned about the development of resistance of M. genitalium to the macrolides, particularly following treatment with a single dose of azithromycin (M. genitalium is slow-growing and may therefore be exposed to sub-optimal concentrations of the drug). Treatment failure with doxycycline is well documented, and in vitro studies have shown that the sensitivity of M. genitalium to levofloxacin and ciprofloxacin is reduced. Moxifloxacin, however, given in an oral dosage of 400 mg once daily for 10 days has proved to be effective.
As his partner has been treated previously, further treatment of her is not indicated.
Pierre who was treated with the short course of azithromycin and metronidazole returns to the clinic 2 weeks later. Once again, C. trachomatis was not detected at the above clinic attendance, and significant bacteriuria was not found in the mid-stream urine specimen. He still complains of urethral discharge and mild dysuria; there are no other symptoms. He had no adverse reactions to the medication. Examination confirms a mucoid urethral discharge with significant numbers (>5 per ×1000 field) of polymorphonuclear leucocytes in a Gram-stained smear.
22.3 What Would You Do Next?
After treatment of urethritis, the inflammatory response in the urethra may take several weeks to resolve, even when the causative organism, if one was identified, has been eradicated. It is therefore worth reassuring him that the urethritis is likely to resolve spontaneously and that further antimicrobial treatment is not indicated.
He returns to the clinic 1 month later. His symptoms have not improved.
22.4 What Do You Do Next?
As an underlying urological abnormality may, rarely, cause recurrent or persistent urethritis, referral to a urologist is the next course of action. If no abnormalities are found, he should be strongly reassured about this is a benign condition that in most cases, will eventually resolve without sequelae. For example, there is no evidence that fertility is impaired.